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General NPI Number Information
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NPI Number | 1417287970
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Entity Type | Organization
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Legal Business Name | ATHELITE ORTHOPEDICS AND SPORTS MEDICINE, LLC
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Dates
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Enumeration Date | 01/06/2010
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Last Update Date | 01/06/2010
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Provider Practice Location Address
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Address Line | 365 S PARK RIDGE RD SUITE 102
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City | BLOOMINGTON
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State | IN
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Zip | 47401-8361
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Country | US
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Telephone | 812-822-2675
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Fax | 812-822-2679
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Provider Business Mailing Address
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Address Line | 365 S PARK RIDGE RD SUITE 102
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City | BLOOMINGTON
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State | IN
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Zip | 47401-8361
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Country | US
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Telephone | 812-822-2675
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Fax | 812-822-2679
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Authorized Official
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Title or Position | MEMBER
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Name | DOUGLAS ALAN FLORY
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Credential | M.D.
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Telephone | 812-822-2675
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207XX0004X
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Taxonomy Name | Orthopaedic Foot and Ankle Surgery Physician
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License Number | 1052068
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License Number State | IN
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